Willerby and Swanland Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our previous assessment in October 2025, governance of the practice was not effective. This follow‑up assessment showed that governance at the practice had improved. Leaders had taken effective action to strengthen systems and oversight. Health and safety and fire risk assessments were more consistent and up to date, staff recruitment files were better organised, and infection prevention and control processes were more standardised. Leaders had improved their oversight of mandatory training requirements, with clearer systems in place to monitor compliance. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. There was a culture of continuous improvement with staff given time and resources to try new ideas.

This service scored 79 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff feedback received was positive about the culture of the practice. Staff felt involved and were able to contribute to the shared direction of the practice. For example, staff were consulted and asked to share their views on how annual leave requests would be handled. As a result of this, a new process was implemented following feedback from the staff.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. At our previous assessment, the provider had just gone through leadership changes. We found that there was now a stable leadership team in place. All staff we spoke with were positive about leaders at the practice and the impact they were making.

We saw the leadership team worked with other practices in the primary care network and were engaged in the development of primary care services within the local area.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The practice had established Freedom to Speak Up arrangements with a practice neighbouring practice manager. This arrangement was reciprocated for the other practice.

Staff were aware of how to raise concerns and fed back to us that they would feel confident to do so if they needed to. Staff were also given training on freedom to speak up and whistleblowing.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who work for them. Staff reported that they felt supported, were treated equally, and were free from bullying and harassment.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued. For example, we saw adjustments to working hours requests were considered for staff.

At our previous assessment, we found that governance arrangements were not fully effective, with unclear roles and responsibilities. There were gaps in how risks, performance and outcomes were monitored. Although some systems and checks were in place, these were not consistently applied or well organised, making it difficult for leaders to assure themselves of compliance.

At this assessment, we found that new processes and systems implemented since the previous assessment were working well. This included updated health and safety policies, fire risk assessments and regular premises checks.

A review showed that there was a standardised approach in place which maintained consistency. The provider had developed the use of Microsoft forms to carry out checks on things such as, fire extinguishers, alarms and emergency lighting. The forms could be assessed through a web link or by scanning a QR code. This meant they were accessible to all staff if they encountered any risks or problems. The forms were also linked to a compliance tracker to ensure that regular checks were taking place. The compliance tracker provided a red, amber, green (RAG) rating depending on when checks were due.

The provider had also updated how they monitored and maintained policies to ensure they were reviewed in a timely manner. Each policy was saved within a compliance tracker which monitored when a policy was due to expire and showed when a review was required.

To ensure appropriate oversight of governance arrangements across the practice, the provider had implemented a “governance calendar” which all managers had access to. This provided weekly reminders for things such as premises checks, staff due appraisals and mandatory training reminders. As all managers had access to this, it ensured that if a manager was absent or on annual leave, it would still be picked up within the management team.

Since our previous assessment, the practice had started the process of keeping digital records for staff files. This meant that all recruitment checks were easily available for managers to review. This included things such as Disclosure and Baring Service checks, professional registrations and vaccine information. All digital files were then linked to a separate compliance tracker which provided a RAG rating to ensure all the necessary documentation was there. It also gave managers a clear oversight for when clinical staff (such as nurses and doctors) were due to update their professional registrations. The provider had also incorporated mandatory training requirements within the compliance tracker; this provided much easier oversight for managers for when staff were due any training.

Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Staff took patient confidentiality and information security seriously.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The practice had an established Patient Participation Group (PPG). There were posters and leaflets in the reception area to inform patients what the PPG had been involved in and to encourage more patients to join. The provider involved the PPG in health promotions. For example, engaging patients who were veterans. The practice also used social media to engage with their patients to promote services and highlight any changes.

The provider worked with other practices within their PCN to offer extended access, and delivered flu and covid vaccination programmes which were carried out at their own premises.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

The practice had a quality improvement plan in place to help drive improvements in services. All staff were encouraged to put forward and test out new ways of working. Since implementing their triage system in June 2024, the practice had designed templates and questionnaires to be sent to patients through shortcuts on their computer system. This process was efficient and saved time for GPs when more information was required or if patients needed to be sent additional information.

The practice demonstrated innovative use of digital systems to support safety and compliance. Microsoft forms were used to standardise premises checks, such as fire extinguishers, alarms and emergency lighting. They were easily accessible to all staff via web links or QR codes, enabling timely reporting of risks or concerns. These forms were then directly linked to a compliance tracker, which provided clear oversight through a RAG rating system to ensure checks were completed at appropriate intervals and to support effective governance oversight.